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nkarman
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Posted: Sun Mar 7th, 2010 06:01 am |
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Just taught an advanced pediatric course this week, and the demo (unfortunately not videotaped) illustrated his idea perfectly. The child was particularly ataxic, and arrived using a posterior rolling walker. His ability to control the walker and steer was non-existent. He was wholly weighted in his UEs, taking no weight through his lowers. He moved using momentum initiated at his head, and had no idea how to keep his feet under his body. The facility hosting the course had been using the LG for over a year, with therapists who had been to at least one full day training prior, and were very enthusiastic users.
I suspended the child inthe litegait and set him loose over ground. Feet went flying out from under him: he had no clue how to use GRFs to generate movement. Used elastic (t-band) to hold hips closer to actuator so they were under his trunk in better alignment. Set him free to chase a ball around the room again, let him explore on his own (postural correction, no BWS), and gave him oportunity to learn (he was very cognitively impaired). Fast forward about 10 minutes. He is guiding the LG around the room beautifully playing ball. Back to walker: lower extremities fully loaded, walking straight to his target with good balance, not veering off course. Now the goals are to d/c the assistive device completely, whereas before the LTG was to use the walker independenty. Sometimes I wonder if failing of manipulating the environment is due to the constuction of the specific intervention plan (similar to critiques I got early on in NDT treatment: in the hands of a
practitioner more skilled in the approach, the approach works better... Or, more crudely put "I am not good enough at it yet, so the treatment is not as effective as the treatment I am quite skilled at."). My point is, that therapist skill is always a factor to consider in any treatment plan, and creative problem solving is a huge part of therapist skill. Hands on correction is easy and obvious. Manipulating a task requires a lot of thought and creativity. (Sorry if that sounds really snarky, I did 8 short trainings and a full day advanced course this week: my frontal lobe is very tired.)
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Debra Widmer-Reyes
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Posted: Sat Feb 28th, 2009 05:54 pm |
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In the school setting- Recently, I performed my own mini-study regarding this idea:the environment creating the potential for change or handling facilitation. After many discussions with the trainer group at MR in August08, I returned determined to go back in September to a few students (clients) and redesign their treatment plans to allow more environment and less to no handling. With 4 students, i moved them primarily back into use of the harness/Walkable/Treadmill- i had progressed them to Walkable, no harness, handlebars and "within handlebars" with interchanging steps of facilitation/independence
I continued to follow my own treatment style where i develop a series of predictable walking patterns with changes in speed, elevation and direction for the children to learn and practice. Each pattern has a name with a visual support that the student picks the order each session. I provided specific mirrors for face forward-visual fixation/ambient training.
I decreased hands-on to a minimum, other than correcting trunk harness/alignment when nec, and continued that practice through December. Sessions are 15-20 minutes 2-4 x weekly. All 4 students decreased general endurance, some gait parameters. Upon return to a mix of hands on and structure in January, all 4 are moving forward. There is a difficult blur between both structure and handling. If structure cannot give the desired outcome, provide alignment. My facilitation is restricted to the trunk, with and without the harness and providing changes of challenge and rest that is specific ot the student. The challenge time requires adult handling and this keeps the student engagement- looking forward to "getting thru" some "hard stuff "(climbing a hill for 10 steps).
The one year old learns to walk by a series of ever changing parameters that are more reflexive and less adpative. With children, providing structure and facilitation to imitate some of these typical changing parameters at the reflexive then adaptive level is more impt to me than the hands or no hands.
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Andrew M. Ball, PT, DPT, PhD
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| Joined: | Tue Dec 26th, 2006 |
| Location: | Charlotte, NC |
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Posted: Sat Jan 10th, 2009 04:21 am |
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Although a good part of my course is devoted to the lack of evidence to support (and in many cases) all of the "air of royalty" that NDT has enjoyed among PT's over the years (and in some cases as you point out, negative evidence), there are a few studies that have shown the clinical value of NDT and should not be ignored.
· Girolami GL, Campbell SK. Efficacy of a neurodevelopmental treatment program to improve motor control in infants born prematurely. Pediatric Physical Therapy. 1994;6:175-184
· Knox V, Evans AL. Evaluation of the functional effects of a course of Bobath therapy in children with cerebral palsy: a preliminary study. Dev. Med Child Neuro. 2002. 44:447-460
· Kerem M, Livanelioglu A, Topcu M. Effects of Johnstone pressusre splints combined with neurodevelopmental therapy on spastic and cutaneous sensory inputs in spastic cerebral palsy. Devel Med & Child Neuro. 2007; 43:307-313
· Adams MA, Chandler LS, Schuhmann K. Gait changes in children with cerbral palsy following a neurodevelopmental treatment course. Pediatric Physical Therapy. 2000;12:114-120.
· Shapiro B, et al. (Long T). The effects of Physical Therapy on Cerebral Palsy: A controlled Trial in Infants with Spastic Diplegia. NEJM. 1998, 318(13) 803-808.
I would argue, however, that in many of the above cases, and argument can be made that it was either the time in treatment, or density of "Therapeutic Events" over treatment session --- that was the primary variable for which positive effect can be attributed, and perhaps not the NDT. Let's not forget, however, that the LiteGait hasn't been around all that long and until recently, faciltation techniques WERE the best way to evoke the greatest number of therapuetic events over unit time.
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Dr. Andrew Ball, PT, DPT, PhD
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Posted: Sat Jan 10th, 2009 04:02 am |
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Very good points. I don't mean to argue for, nor against, the use of facilitation while in the BWSTT system --- as I can see clinical value to both approaches depending on the specific clinical situation. In general, (and I think you read into my bias), I try to stay as hands-off as possible, facilitating only when there is a pathomechanic pattern. It's hard, however, to let all that NDT and PNF continuing education training go to waste! Sometimes I likely intervene too soon, but I've also seen pathomechanic patterns persist and not self-correct. I think many clinicians new to the LiteGait have a desire to intervene and facilitate too much, in fear that while "perfect practice makes perfect," imperfect practice makes for chaos and entropy. Again, it's not quite that simple.
I think a better question to ask is, "How does facilitation required when using BWSTT compare to that when using other treatment environments such as hippotherapy or a ball?" To which I'd respond, "The least of all three, for sure." If not BWSTT, I'd opt for hippotherapy, but even then, the environment (and induced therapeutic events) isn't entirely automated or uniform. Certainly, the least therapeutic events per session occur on the therapy ball as the clinician must not only facilitate the patient when necessary, but manipulate the treatment environment as well.
Dr. Andrew Ball, PT, DPT, PhD
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nkarman
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Posted: Thu Jul 31st, 2008 03:47 am |
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OK, I finally got back on to respond to this again...
BOTH NDT AND PNF are facilitation models, in which a peripherally applied stimulus is designed to promote a specific motor response (bottom-up models). This is in contrast to a "motor control" or top-down model in which the person must problem-solve and respond to environmental or task constraints/conditions.
I am a bit tired of the stranglehold that NDT (and, to a lesser extent, other facilitation models) have on neurological intervention, particularly in pediatrics, despite a real lack of any sort of research data to support their use. I just finished reviewing an article (Cherng, et al, 2007) for an upcoming training, and (although it was not a focus of the article at all, not even discussed) I think that the (granted, very limited) data supported the use of BWSTT over NDT, and even suggests that NDT was ineffective. I was disturbed that even during the “experimental” intervention period, NDT-based intervention was included (the conditions were “regular treatment” and “BWS + regular treatment)- implying that BWS gait training as a stand-alone intervention method would be inadequate. They used outcome measures that appeared to have been selected to be sensitive to changes being “targeted” by “regular treatment” and there was no significant change in those measures for either condition (crossover design).
I would argue that “therapeutic events” can take place absent hand placement on the therapist’s part. An action can include environmental manipulation (of any condition), or even providing a visual or auditory cue to vary performance. Providing targets or cues that focus on results rather than performance can actually yield superior outcomes.
Patterning and facilitation in a BWSTT system can be different from each other. Patterning is essentially passive in nature, whereas facilitation (using a broad, bottom-up model definition) can still require an active response. I would argue that both are of limited value, with the passive performance of lesser/no value (other than, perhaps, maintenance of ROM).
The argument you make about evoking a response via disturbance to the system would promote a “hands-off” approach in BWSTT. The treadmill itself (manipulated through belt speed, incline, etc) is the disturbance- no need for hands.
Last edited on Thu Jul 31st, 2008 03:50 am by nkarman
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WebKeeper
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Posted: Sun Mar 11th, 2007 06:07 pm |
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There is no time limit on active sessions. There was a 15 minute inactivity time limit during editing. That has been raised to 60 minutes. But that applies to an open posting edit/reply window with no keystrkes.
I suggest for lengthier replies to do so in Word or Notepad (word processing software) first and then cut and paste it to the Posting editor. That way if it takes you time to form your response you do not lose anything.
The Instructors can also edit their own posting for a day after they post it. So you could add to or change what you have posted
Happy Posting
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nkarman
Instructor
| Joined: | Sat Jul 15th, 2006 |
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Posted: Thu Mar 8th, 2007 01:51 am |
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AARGH- I wrote a long, detailed response, and the thing timed out when I sent it to post, and now it is LOST IN THE ETHER. Can you increase the time on this thing?
NK
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Andrew M. Ball, PT, DPT, PhD
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| Joined: | Tue Dec 26th, 2006 |
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Posted: Tue Feb 27th, 2007 03:46 am |
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Amir,
That's a great question of treatment philosophy. . . but in practical practice, the lines are a little more blurred than that. In short, I'd agree with the idea of manipulating the environment, though not quite for the same reasons suggested. It's hard to have this kind of discussion in terms of integration of NDT vs. PNF, with BWSTT . . . because the lines are being increasingly blurred. Though a SWEEPING GENEREALIZATION, "old timers" usually think of NDT techniques as those that help a patient through a movement pattern, and PNF techniques as those in which the patient reacts in a specific manner in response to a therapist evoked action.
That said, I learned quite a bit of the latter during NDT training in Lois Bly's course (e.g. a TON of PNF that, at the time, I and others would certainly, and in error, have assumed was strictly NDT), which personally, I find much more applicable to treating a child in the LiteGait system. That's my opinion, based upon the suggestion of evidence mind you, that one of the more valuable aspects of BWS-TT systems is increased frequency of "therapeutic events" in a treatment session vs. traditional therapy. I define this as a therapist (or gait-trainer) induced action followed by a patient reaction.
I don't see much value to patterning, which is essentially what facilitation in a BWSTT system is. I've not known any Mobility Research presenter I've known to disagree with that position.
Just as one of the primary treatment values of NDT is, in my opinion, less the patient's conforming to a facilitated movement pattern and more response to an evoked balance disturbance when on a therapy ball, so is the case in the LiteGait --- where one of the primary treatment values is the ability of the patient to make rapid equilibrium responses to evoked disturbances. It is my understanding that FACILITATION of the child's hip through the swing phase is not only NOT what's taught in the NDT curricula (certainly not in mine, as that would result in a "John Wayne" gait) --- but when applied to a child while walking in a BWSTT system, would diminish the outcome effectiveness of the system borne from the dance of evoked disturbance/patient response.
Sounds like a good study . . . but like I said, it's VERY hard to distinguish the two. If I had to say, I'd agree with the therapist you spoke with and submit that a "evoke and patient reaction" approach yields better results. I'd add, however, that way, way, way, too many therapists assume, in error, that the LiteGait is a facilitation (rather than reactionary system) and avoid using it out of hand. Technically it is neither . . . it is the THERAPSIT that works in a facilitation (less effective) or "evoked disturbance" (more effective) manner.
Drew
Last edited on Tue Feb 27th, 2007 04:01 am by Andrew M. Ball, PT, DPT, PhD
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amirseif
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Posted: Mon Feb 19th, 2007 12:52 am |
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I just came back from what has to be one of the best CSM conferrences ever. Not only the crowds were there, the quality of the discussions were very high. There was one conversation specifically that I would like your comments on.
Someone suggsted that she would rather the environmrnt was manipulated to cause the patient to practice gait rather than facilitate the movement. She distinguished between extending the stance by preventing a quick step and facilitating at the hip to cause a more normal swing. In one the motor plan is by the patient's, in the other the clinician "interfers" with the motor plan. The dependency on that correction was part of the objection to facilitation.
What do you all think?
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